Patient service

Diabetes medical history form

Visiting our practice for the first time? Please fill in the diabetes-specific form before your appointment.

Step 1 of 517%

Patient information
Complaints & risk factors
Known diseases
Medical history & personal details
Diabetes
Summary

Patient information

Name *

First nameLast name

PhoneE-MailName of your family doctor?

Which other specialists are you still under treatment with? (Please write down the name.)

CardiologistNephrologistNeurologistPulmonologistOthersOrthopedistDermatologistGynecologistUrologist

Do you participate in the Disease-Management Program (DMP)?

yesno

Back to the medical history forms

Your answers stay in your browser. They are not transmitted to the practice – they only leave your device if you have the form sent to yourself by e-mail.